A team of Columbia University researchers has determined that mandatory outpatient treatment for people with severe mental illnesses has led to a drop in violent behavior. The study was published in February in the journal Psychiatric Services.

Professor Bruce Link

The study is the first to fully assess the merits of Kendra’s Law, which mandates outpatient care for people who are deemed “unlikely to survive safely in the community without supervision,” according to the New York State Office of Mental Health. Enacted in 1999, the law is named after Kendra Webdale, who died after being pushed in front of a New York City subway train by a man diagnosed as having schizophrenia. Kendra’s Law, which was renewed in 2005, is set to expire this summer. At present, 42 states, including New York, have laws mandating outpatient care for individuals with severe mental illnesses.

Since its enactment, the law has met some opposition. Critics question the method of forcing people into treatment, fearing consequences such as increased stigma, decreased self-esteem and compromised civil freedoms. But the Columbia researchers say there are clear benefits to such care. More than 1,800 New Yorkers are currently enrolled in a court-ordered outpatient treatment program.

“Outpatient commitment for people with mental illnesses is enormously controversial—it’s been heralded as necessary and effective by some, and as overly coercive and counterproductive by others. But our study has found few of the negative consequences feared by critics of Kendra’s Law,” said Bruce Link, professor of epidemiology and sociomedical sciences at Columbia and lead investigator of the study.

To conduct their study, the researchers followed 76 patients in New York City clinics between 2003 and 2006. The individuals were ordered to undergo outpatient care due to histories of violence and non-compliant behavior. Those in the study were compared with a carefully matched control group of 108 outpatients with mental illness enrolled in the same clinics. These patients, however, were placed into less intense treatment programs because they demonstrated fewer propensities toward violent behavior and were deemed more likely to follow through with treatment regimens.

The groups were compared on the following criteria: psychotic symptoms, suicide risk, serious violence perpetration, quality of life, illness-related social functioning, and perceived coercion and stigma. All participants were screened by a psychiatrist or doctoral-level psychologist unaffiliated with the study for capacity to provide informed consent. Interviews were conducted over a year at three-month intervals.

The researchers found that the patients in mandatory outpatient treatment—who had more violent histories—were four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. They also found that patients who underwent mandatory treatment experienced higher social functioning and slightly less stigma, thus countering claims that mandatory outpatient care is a threat to self-esteem.

“Our study has found that Kendra’s Law has lowered the risk of violent behaviors, reduced thoughts about suicide and enhanced capacity to function despite problems with mental illness,” said Link, who has a joint appointment with Columbia’s sociology department and the Mailman School of Public Health. Link has a longtime interest in the connection between mental illnesses and violent behaviors, and the stigma of mental illness. “Both are critical issues in Kendra's Law,” he said.

The Columbia study, conducted in collaboration with the University of Michigan and the New York State Psychiatric Institute, was funded by the New York State Office of Mental Health.